Holder Reporting Form - Nebraska State Treasurer Page 2
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1
2Holder Reporting Form
<<< THIS PAGE MUST BE INCLUDED WITH YOUR REPORT >>>
Place a checkmark by the category which most closely describes your organization:
Banking/Trust
Other Business Association
Schools, Colleges
Savings & Loan
Retail
Churches
Credit Union
Construction
Health Care Facilities
Life Insurance
Services
Government
Other Insurance
Manufacturing
Utilities / Cable
Mutual Funds
Transportation
Reciprocal
Finance/Investments
Oil & Gas
If you are a non-insurance entity:
If you are an insurance entity:
List number of shareholders:
List number of policies in force:
List dollar volume of sales for last fiscal year:
List dollar volume of sales for last fiscal year:
State of
County of
I, , Being first duly sworn on oath depose and state that
I have caused to be prepared and have examined this report consisting of pages totaling
$ as to property presumed abandoned under the Nebraska Unclaimed Property Act for the
year ending as stated; that I am duly authorized by the holder herein to execute this report; and I believe
that said report is true, correct and complete as of said date, exception for such property as has ceased
to be abandoned.
Signature of Company Representative:
Title of Company Representative:
Subscribed and sworn to before me this
day of
, 20
(Please place Notary Seal here)
Signature of Notary:
MAILING ADDRESS:
Nebraska State Treasurer
Unclaimed Property Division
809 P Street
Lincoln, NE 68508-1390
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Parent category: Financial